BELLE FOUNTAIN NURSING
RIVERVIEW, MI  48195

Medicare Provider Number: 235376
Cost report status: Settled Without Audit
[Record Code 1104894 - 2010]

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APPORTIONMENT OF ANCILLARY AND OUTPATIENT COST Provider CCN: 235376
PERIOD:
FROM 10/01/2012
TO 09/30/2013
WORKSHEET D PART I
SNF - SNF Medicare - Title XVIII
PART I - CALCULATION OF ANCILLARY AND OUTPATIENT COST
Cost Center Description Ratio of Cost to Charges (from Wkst. C, col. 3) Health Care Program Charges Healthcare Program Cost  
Part A Part B Part A ( col. 1 x col. 2 ) Part B ( col. 1 x col. 3 )
1 2 3 4 5
ANCILLARY SERVICE COST CENTERS
40 Radiology ### ### ### 40
41 Laboratory ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 43
44 Physical Therapy ### ### ### 44
45 Occupational Therapy ### ### ### 45
46 Speech Pathology ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients ### ### ### 48
49 Drugs Charged to Patients ### ### ### 49
50 Dental Care - Title XIX only     50
51 Support Surfaces 51
52 Other Ancillary Service Cost 52
OUTPATIENT COST CENTERS            
60 Clinic 60
61 Rural Health Clinic (RHC) 61
62 FQHC 62
63 Other Outpatient Service Cost 63
71 Ambulance (2) 71
100 Total (sum of lines 40 - 71)   ### ### 100
(1) For titles V and XIX use columns 1, 2 and 4 only.
(2) Line 71 columns 2 and 4 are for titles V and XIX. No amounts should be entered here for title XVIII.
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4124)
08-16   Rev. 7